Source: Claus, L. M. (1991) TQM A Healthcare Application, Total Quality Management, Vol. 2, No. 2.
Voss and O’Brien17 have no doubt but that successful quality management requires not just good procedure and documentation, but excellent equipment and a good skill base; it also depends on the integration of quality concepts and practices into all business processes. Quality management requires a new set of interrelationships which must affect all parts of an organisation, including quality communication, sustained commitment and broad based staff involvement. The demands of quality management require a constancy and tenacity of purpose18. If the quality vision is to be cascaded through the organisation from the top down, it requires the co-operation of lower level staff19. Interestingly not many organisations implementing TQM bother to win the co operation of lower level staff20 Cases in the NHS21 show that, where management has led strongly, and has not yet secured the beliefs and commitment of those at the operational levels, the TQM initiative remains at the level of training and the raising of consciousness. In order for TQM to work, it is first essential to develop a strategy that aims to emphasize quality as an integral part of every individuals task, to encourage the commitment of all members of staff to create an organisational structure focused on all aspects of clinical service and to promote customer orientation22. Most importantly, management understanding, conviction, commitment and involvement are essential. Those in management will have to be seen to practice what they preach and to ‘work-the-job’23. Thus, the implementation of TQM will require the creation of an accompanying management structure and of an action plan which defines the objectives, policies and principles of the hospital unit. Also important, is the formation of a total quality strategy committee composed of staff drawn from multiple disciplines, responsibility of which is to oversee the TQM process24. Measurement of quality is another important ingredient for the success of TQM. ‘What cannot be measured, cannot be managed’ argue Haigh and Morris25. Roy26 suggests that for ‘quality’ to succeed in the NHS, quality standards will need to be identified throughout directorates and units and that the associated standards should be monitored and evaluated continuously. This will lead to an improvement in the efficiency and effectiveness of services provided. Additionally, the nature of the NHS as a service provider, and the limited human/financial resources available, make it imperative that an incremental
NHS is ‘sustainable quick-fixes’ through a process-led strategy. This will ensure that the NHS builds on any early returns to motivate people.
Nevertheless, it has been identified that the nature of healthcare organisations works against implementing TQM28. There is a hierarchical structure with conventional reporting relationships and the workforce is multidisciplinary; thus, it cannot be managed like most employees within the commercial sector. Moreover, consultants make decisions which dominate every aspect of a hospital’s activity, hence, any impetus for change should always come from clinicians. Similarly, Melum and Sinioris29 contend that if TQM is to be successful in a hospital setting, consultants must play a central role. But they note that achieving substantial consultant involvement in TQM is one of the most difficult and paradoxical challenges facing healthcare executives. Traditional TQM paradigms ask consultants to support a strategy to ensure the survival of an organisation. However, the primary identification of such consultants is to their profession. Healthcare organisations can maximise their chances of successfully appealing to consultants by ensuring that their strategy meets at least four criteria;
Management commitment to TQM and action
Identification of a ‘Champion’ amongst the consultant hierarchy Effective differentiation of TQM and quality assurance
Development of improvement projects that address consultants top- priority problems
Furthermore, hospitals should address the three roles consultants play: customer, processor, and supplier; emphasising improvement in clinical outcomes and a reduction in patient waiting time.
Melum and Sinioris further suggest three implementational strategies which are imperative in building consultant support for TQM:
(1) We’re in this together - make consultants full partners in the organisation’s TQM effort from the beginning
(2) Prove it first: prove the validity of TQM to consultants through demonstration projects before asking them to participate
(3) Help consultants help themselves - implement TQM in the consultants’ office practice; clinical areas
These strategies are consistent with the view of Fried30, who notes that ‘attempting to impose changes (TQM) in medical practice from the administrative side without clinical support is a recipe for disaster’.
However, the issue of consultant superiority as implied by Fried, has been established as one of the reasons for the failure of TQM in the NHS. Pollitt31 argues that the government’s approach to TQM in the NHS is firmly based on the principle that the quality of medical work can only be reviewed by a doctor’s peers; hence, Medical Audit. In consequence, the 23 TQM pilot schemes now have a programme of total quality minus medical quality; representing a ‘hollow-centred’ rather than a ‘totality’ approach to TQM. The question then arises: ‘Is quality for the customer or for the provider?’. The author is of the view that, the customer is the central thrust of any quality improvement programme. Supporting the view for a totality approach to quality, Batalden et al32, outlined what the healthcare leadership must learn in order to implement TQM successfully with the appropriate focus:
Management must learn the meaning of quality, including an understanding of the importance of the customer.
Top management must sponsor and encourage the continuous improvement of quality, including the wise use of teams that can work effectively to improve systems and other processes.
ones. The reality is that for TQM to work in healthcare, both the models of TQM and professional bureaucracy must be accommodated33:
TABLE 6
Professional TQM
Individual responsibilities Collective responsibilities
Professional leadership Managerial leadership
Autonomy Accountability
Administrative authority Participation
Professional authority ^V ersus - > Performance/Process expectations
Goal expectations Flexible planning
Rigid planning Benchmarking
Response to complaints Concurrent performance appraisal
Retrospective performance appraisal Continuous improvement
Quality assurance
Source: McLaughlin and Kaluzny, 1992
McLauglin and Kaluzny34 suggest 11 actions which they believe must be undertaken for management to function well in a TQM environment:
(i) Redefine the role of the professional (2) Redefine the corporate culture (3) Redefine the role of management
(4) Empower the staff to analyze and solve problems (5) Change organisational objectives
(6) Develop mentoring capacity
(7) Drive the benchmarking process from the top (8) Modify the reward system
(9) Go outside the health industry for model (10) Set realistic time expectations
(11) Make TQM programme a model for continuous improvement
However, McLaughlin and Kaluzny’s 11 actions represent a lot of theory without back up by tools. There is a big difference between suggesting actions necessary for TQM and showing someone ‘how to do it?’. It is important that organisations learn to
purpose-build in the implementation of TQM rather than doggedly following prescriptive packages.
According to Collard (1989)35, a successful TQM programme should be based on the following principles:
Top management commitment Attitude change
Continuous improvement Strengthened supervision Extensive training
Recognition of performance
Collard further suggests that the implementation process involves the establishment of: "A steering committee led by senior management and the quality manager, the facilitator and key functional heads. Its role is to set priorities and allocate resources and ensure that projects meet their objectives. An interdisciplinary task force should be set-up by management aimed at solving specific problems. Furthermore, improvement groups/quality circles should be set-up within the same work area, composed of operational or front line s ta ff.
Collard notes that this group should be voluntary and allowed to choose its own improvement projects. Collard further suggests what he calls a typical TQM implementation plan:
FIGURE 18: A TYPICAL IMPLEMENTATION PLAN
/ DETAILED BRIEFING \ OF SENIOR MANAGEMENT REVIEW OF ORGANISATIONAL
NEEDS
OUTLINE DESIGN OF IMPLEMENTATION
MANAGEMENT WORKSHOPS TO DESIGN DETAILED IMPLEMENTATION PROGRAMME
LAUNCH OF PROGRAMME - PUBLICITY
-DETAILED BRIEFING
ESTABLISHMENT OF TASK GROUPS, PILOT IMPROVEMENT GROUPS
6
COMPLETION OF INITIAL PILOT PROJECTSSource: CoIIard (1989) Total Quality Success Through People, IPM Publication
Similarly Fenwick36 suggests ‘five easy lessons leading to the implementation of TQM’: (1) Establish the foundation
• Set strategic objectives • Define a vision statement (2) Build an infrastructure
• Establish a TQM council • Appoint a TQM executive
(3) Educate the workforce
• Conduct employee surveys • Hold executive workshops • Train management
• Train other personnel (4) Initiate process improvement
• Identify candidate processes • Establish benchmarks (5) Establish communication channels
• Publish letters to employees
• Establish other TQM media techniques
However, the model put forward by Collard and Fenwick respectively seems inappropriate for the implementation of TQM in the NHS because they fail to build into it the flexibility required for the integration of other numerous initiatives such as the Patient Charter and Executive Letter Communications, to name but two. Additionally, their model is based on the incremental continuous improvement approach which has been established as being inappropriate for the NHS37. There are, however a number of divergent views among commentators about the best approach to the implementation of TQM. Beer and Walton38 argue that ‘change’ (TQM), is not brought about by following a grand master plan but by continually adjusting direction and goals. The greatest obstacle to revitalization, they contend, is the idea that it comes through companywide change programmes. This assertion is consistent with the views of one quality manager in the NHS who the author interviewed as part of this research. She argued that ‘organisationwide programmes are problematic because of the Department of Health’s (DOH) constant intervention’. The question she posed was "Why design a five year implementation plan when you are not sure of government intention two months later?"39 In practice, therefore, health service managers are bound to develop
(1) Technical quality, which is concerned with employment of specialist knowledge and expertise.
(2) Generic quality, concerned with agreed standards of conduct, i.e. in relationship with patients and colleagues.
(3) Systemic quality - making sure the organisation works well in a coherent fashion.
Joss et al, note that the NHS has made more progress in technical quality41. However, Joss et al, failed to note ‘why’ there exist three rather than one systematic approach to quality. From empirical evidence, it is the author’s contention that what exists in the NHS is the professionals’ approach to quality. The reason being that the NHS is still a professionally dominated organisation. The professional staff are yet to imbibe the holistic view of quality. Until such a time when there will be a change in the stratificated culture, the professionally oriented quality initiative will dominate. Moreover, the customer has no real choice, irrespective of whether or not a patient’s needs are met, the patient has no reasonable alternative source of provision.
According to Beer et al,42 TQM is about culture change encompassing six steps: (1) Mobilize commitment to change through joint diagnosis of business
problems
(2) Develop a shared vision of how to organize and manage for competitiveness
(3) Foster consensus for the new vision, competence to enact it, and cohesion to move it along
(4) Spread revitalization to all departments without pushing it from the top (5) Institute formal policies, systems and structures
(6) Monitor and adjust strategies in response to problems
However, Beer et al, fail to establish ‘why’ TQM is about culture change, nor do they suggest in what context the six steps which they identify are to be implemented. Nonetheless, the sustainable transformation of an organisation to a TQM culture requires a balance between organisational systems, skills and techniques (the way) with the fundamental attitudes and values of employees (the will)43:
FIGURE 19 * FOCUS * LEADERSHIP * ALIGNMENT * SYNERGY The Way The Will * METHODS * TOOLS * TECHNIQUES
Without the development of the will, the ongoing success of TQM requires a large amount of attention, effort and energy to work against the fundamental status-quo in an organisation which dictates that ‘things should be done the way they have always
• Is supported by committed and a fundamentally aware leadership. In contrast, in the NHS most Trust Boards are committed to winning service contracts. Thus, the leadership is financially driven.
• Is accompanied by a plan to ensure that the behaviours encouraged are aligned with those required. It has been argued that, in the NHS, there exists a failure on the part of management to effectively re-align the organisational culture behind quality initiatives45.
• Generates synergy as a result of the alignment of the TQM concepts and philosophies with the organisation’s systems and policies.
The ‘why’ aspect of the model can be taught. However, in the NHS, the ‘WILL’ for ‘TQM’ is yet to be fully developed due to a number of ongoing and conflicting quality initiatives and concurrent government restructurings. Thus, for TQM to succeed, a ‘total’ re-orientation of employee beliefs and values is required. This is consistent with the views of Thomas Watson Snr., the founder of IBM, who noted: "Any great corporation, one that has lasted over the years, will find that it owes its resiliency not to its form of organisation or administration skills, but to the power of values and beliefs and the appeal these values and beliefs have on its people"46.
For Arikian47 there are five steps to quality improvement;
Empowering employees by providing feedback and reinforcing attitudes and behaviours that support quality and productivity.
Committing to and supporting the TQM philosophy by top management, whose role is to set examples and guide change at all levels in the organisation.
Creating an atmosphere of trust.
Developing problem solving teams.
Nonetheless, Arikian notes that these steps to change should be undertaken by a nursing management team thoroughly committed to the TQM philosophy. The nursing team, she suggests, must demonstrate patience and persistence during the process of introduction and implementation. Graves48 argues that, where management is concerned with culture change the following fundamental issues should be addressed:
Behavioural change: change happens more quickly and more often when it concentrates on changing behaviours:
Focus on a few objectives - on those things that matter most to the customers and to the company.
Avoid oversimplification by use of slogans that convey the wrong message.
Continuous process improvement groups should be developed to improve processes.
However, the author disagrees with the dicta of Graves49 and Arikian50 that TQM is about culture change. Culture change is as a consequence of an ‘effective’ implementation of TQM and not the ‘be all and end all’ of TQM. Any TQM initiative, particularly in the NHS, which adopts culture change as the first priority in its TQM process will falter. Thus, the process of change which TQM encourages, requires first and foremost active leadership and commitment from top management. This would ensure that TQM becomes the way the organisation operates, regardless of the nature of the cultural change process.
FIGURE 20
BEH AV IO URAL A SPEC T
LEA D ER SH IP POSITIVE WORK ENVIRONMENT